Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Wound cleaning methods

Optimal Compression Therapy and Wound Care for Venous Ulcers

Venous leg ulcers remain a major public health issue with significant economic impact. Two main components of the management of patients with venous leg ulcers are compression therapy and wound care. This article addresses principles and specific aspects of compression therapy and focal wound care for patients with venous leg ulcers.

Water for wound cleansing

Background  Various solutions have been recommended for cleansing wounds, however, normal saline is favoured as it is an isotonic solution and is less likely to interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost-effective; however, there is an unresolved debate about its use. Objectives  The objective of this review was to assess the effects of water compared with other solutions for wound cleansing. Search strategy  Randomised and quasi-randomised controlled trials were identified by electronic searches of Cochrane Wounds Group Specialised Register (June 2004), MEDLINE (1996-2004), EMBASE (1980-2004), CINAHL (1982-2004), and the Cochrane Controlled Trials Register (Issue 2, 2004). Primary authors, company representatives and content experts were contacted to identify eligible studies. Reference lists from included trials were also searched. Selection criteria  Randomised and quasi-randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing. Data collection and analysis  Trial selection, data extraction and quality assessment were carried out independently by two reviewers and checked by a third reviewer. Differences in opinion were settled by discussion. Some data were pooled using a fixed effects model. Main results  Five trials were identified that compared rates of infection and healing in wounds cleansed with water and normal saline; three compared cleansing with no cleansing and one compared cleansing with procaine spirit with water. There were no standard criteria for the assessment of wound infection across the trials which limited the ability to pool the data. The major comparisons were water versus normal saline, and tap water versus no cleansing. For chronic wounds, the relative risk of developing an infection when cleansed with tap water compared with normal saline was 0.16 (95% CI 0.01-2.96). Use of tap water to cleanse acute wounds in adults was associated with a lower rate of infection than saline (RR 0.55, 95% CI 0.31-0.97). The use of tap water to cleanse acute wounds in children was not associated with a statistically significant difference in infection, when compared with saline (RR 1.07, 95% CI 0.43-2.64). Similarly, no statistically significant differences in infection rates were seen when wounds were cleansed with tap water versus not cleansed at all (RR 0.81, 95% CI 0.31-2.12). Likewise, there was no difference in the infection rate in episiotomy wounds cleansed with water or procaine spirit. The use of isotonic saline, distilled water and boiled water for cleansing open fractures also did not demonstrate a statistically significant difference in the number of fractures that were infected. Conclusions  Although the evidence is limited one trial has suggested that the use of tap water to cleanse acute wounds reduces the infection rate and other trials conclude that there is no difference in the infection and healing rates between wounds that were not cleansed and those cleansed with tap water and other solutions. In the absence of drinkable tap water, boiled and cooled water as well as distilled water can be used as cleansing agents.

Water for wound cleansing

BACKGROUND

Although various solutions have been recommended for cleansing wounds, normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective; however, there is an unresolved debate about its use.

OBJECTIVES

The objective of this review was to assess the effects of water compared with other solutions for wound cleansing.

SEARCH METHODS

For this fourth update we searched the Cochrane Wounds Group Specialised Register (searched 9 November 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (2010 to October Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, November 8, 2011); Ovid EMBASE (2010 to 2011 Week 44); and EBSCO CINAHL (2010 to 4 November 2011).

SELECTION CRITERIA

Randomised and quasi randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing.

DATA COLLECTION AND ANALYSIS

Two review authors independently carried out trial selection, data extraction and quality assessment. We settled differences in opinion by discussion. We pooled some data using a random-effects model.

MAIN RESULTS

We included 11 trials in this review. We identified seven trials that compared rates of infection and healing in wounds cleansed with water and normal saline; three trials compared cleansing with no cleansing and one trial compared procaine spirit with water. There were no standard criteria for assessing wound infection across the trials, which limited the ability to pool the data. The major comparisons were water with normal saline, and tap water with no cleansing. For chronic wounds, the relative risk of developing an infection when cleansed with tap water compared with normal saline was 0.16, (95% CI 0.01 to 2.96). Tap water was more effective than saline in reducing the infection rate in adults with acute wounds (RR 0.63, 95% CI 0.40 to 0.99). The use of tap water to cleanse acute wounds in children was not associated with a statistically significant difference in infection when compared to saline (RR 1.07, 95% CI 0.43 to 2.64). We identified no statistically significant differences in infection rates when wounds were cleansed with tap water or not cleansed at all (RR 1.06, 95% CI 0.07 to 16.50). Likewise, there was no difference in the infection rate in episiotomy wounds cleansed with water or procaine spirit. The use of isotonic saline, distilled water and boiled water for cleansing open fractures also did not demonstrate a statistically significant difference in the number of fractures that were infected.

AUTHORS' CONCLUSIONS

There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it. However there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.

Water for wound cleansing

BACKGROUND

Various solutions have been recommended for cleansing wounds, however normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective, however, there is an unresolved debate about its use.

OBJECTIVES

The objective of this review was to assess the effects of water compared with other solutions for wound cleansing.

SEARCH STRATEGY

Randomised and quasi-randomised controlled trials were identified by electronic searches of Cochrane Wounds Group Specialised Register (June 2007), MEDLINE (1996-2007), EMBASE (1980-2007), CINAHL (1982-2007) and the Cochrane Controlled Trials Register (Issue 3; 2007). Primary authors, company representatives and content experts were contacted to identify eligible studies. Reference lists from included trials were also searched.

SELECTION CRITERIA

Randomised and quasi randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing.

DATA COLLECTION AND ANALYSIS

Trial selection, data extraction and quality assessment were carried out independently by two authors and checked by a third author. Differences in opinion were settled by discussion. Some data were pooled using a random effects model.

MAIN RESULTS

Eleven trials were included in this review. Seven trials were identified that compared rates of infection and healing in wounds cleansed with water and normal saline, three trials compared cleansing with no cleansing and one trial compared procaine spirit with water. There were no standard criteria for assessing wound infection across the trials which limited the ability to pool the data. The major comparisons were water with normal saline, and tap water with no cleansing. For chronic wounds, the relative risk of developing an infection when cleansed with tap water compared with normal saline was 0.16, (95% CI 0.01 to 2.96). Tap water was more effective than saline in reducing the infection rate in adults with acute wounds (RR 0.63, 95% CI 0.40 to 0.99). The use of tap water to cleanse acute wounds in children was not associated with a statistically significant difference in infection when compared to saline (RR 1.07, 95% CI 0.43 to 2.64). No statistically significant differences in infection rates were seen when wounds were cleansed with tap water or not cleansed at all (RR 1.06, 95% CI 0.07 to 16.50). Likewise, there was no difference in the infection rate in episiotomy wounds cleansed with water or procaine spirit. The use of isotonic saline, distilled water and boiled water for cleansing open fractures also did not demonstrate a statistically significant difference in the number of fractures that were infected.

AUTHORS' CONCLUSIONS

There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it. However there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.

Effectiveness of solutions, techniques and pressure in wound cleansing

BACKGROUND

This systematic review updates a previous review published in 2001. Cleansing is a vital component of wound management; however; little attention has been give to the solutions and techniques used for cleansing purposes. The objective of this review was to assess the effectiveness of different solutions, pressures and techniques used for wound cleansing to prevent infection and promote wound healing.

SEARCH STRATEGY

Randomised and clinical controlled trials were identified using the Cochrane Central Register of Controlled Trials (CENTRAL). Additional searches of other databases and hand searches of journals and bibliographies was undertaken to identify further trials.

SELECTION CRITERIA

All randomised and clinical controlled trials involving adults and/or children whose wounds were cleaned with commercial cleansers, normal saline, water, chlorhexidine, hydrogen peroxide or povidone-iodine were eligible for inclusion. Studies that utilised solutions for preoperative skin cleansing, compared solutions for burns or dental procedures, and those that compared dressings for patients with ulcers were excluded from this review. Outcomes included rate of healing, incidence of infections or levels of bacterial count. Selection of potential articles, assessment of methodological quality and data abstraction was conducted independently by two reviewers. Trials with similar patients, comparisons, and outcomes were pooled. The data were analysed using Cochrane Review Manager 4.2. Where pooling was inappropriate, trials are discussed in a narrative review.

RESULTS

Fourteen randomised controlled trials were included that compared various solutions for wound cleansing. The evidence indicates that there is no difference in the infection and healing rates in acute and chronic wounds cleansed with either tap water or normal saline. An irrigation pressure of 13 psi is effective for cleansing wounds and reducing infection without causing tissue trauma.There were no studies comparing common techniques for wound cleansing such as swabbing or scrubbing. Showering postoperative wounds did not demonstrate any difference in infection rates; however, it increased the morale of the patient. Whirlpool therapy was effective in reducing inflammation and pain in surgical wounds.

CONCLUSIONS

These conclusions are based on the best available clinical evidence. However, there is an urgent need to support these findings with rigorous research as some of the conclusions are based on single studies with limited sample sizes.Solutions for wound cleansing:Pressure for wound cleansing:Techniques for wound cleansing.

Water for wound cleansing

BACKGROUND

Various solutions have been recommended for cleansing wounds, however normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective, however, there is an unresolved debate about its use.

OBJECTIVES

The objective of this review was to assess the effects of water compared to other solutions for wound cleansing.

SEARCH STRATEGY

Randomised and quasi-randomised controlled trials were identified by electronic searches of Cochrane Wounds Group Specialised Trials Register, MEDLINE, EMBASE, CINAHL, and the Cochrane Controlled Trials Register. Primary authors, company representatives and content experts were contacted to identify eligible studies. Reference lists from included trials were also searched.

SELECTION CRITERIA

Randomised and quasi randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing.

DATA COLLECTION AND ANALYSIS

Trial selection, data extraction and quality assessment were carried out independently by two reviewers and checked by a third reviewer. Differences in opinion were settled by discussion. Some data were pooled using a random effects model.

MAIN RESULTS

Three trials were identified that compared rates of infection and healing in wounds cleansed with water and normal saline, two compared cleansing with no cleansing and one compared procaine spirit with water. There were no standard criteria for the assessment of wound infection across the trials which limited the ability to pool the data. The major comparisons were water vs normal saline, and tap water vs no cleansing. For chronic wounds, the odds of developing an infection when cleansed with tap water compared with normal saline was 0.16, 95 % Confidence Interval (CI) 0.01, 2.96. Use of tap water to cleanse acute wounds was associated with a lower rate of infection than saline (OR 0.52, 95 % CI 0.28, 0.96). No statistically significant differences in infection rates were seen when wounds were cleansed with tap water or not cleansed at all (OR 1.06, 95 % CI 0.06, 17.47). Similarly there was no difference in the infection rate in wounds cleansed with water or procaine spirit and those cleansed with isotonic saline, distilled water and boiled water (OR 0.55, 95 % CI 0.18,1.62).

REVIEWER'S CONCLUSIONS

Although the evidence is limited one trial has suggested that the use of tap water to cleanse acute wounds reduces the infection rate and other trials conclude that there is no difference in the infection and healing rates between wounds that were not cleansed and those cleansed with tap water and other solutions. However the quality of the tap water should be considered prior to its use and in the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.